MEDICARE: MS. REBECCA LUCILLE A.P.R.N. PSYCHIATRIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	3423224405	UT

General Provider Information

NPI Number	:	1417934324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REBECCA LUCILLE A.P.R.N. PSYCHIATRIC

Provider Business Mailing Address
First Line	:	337 N MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-1633
Country	:	US
Telephone Number	:	801-633-5458
Fax Number	:

Provider Business Practice Location Address
First Line	:	5965 S 900 E
Second Line	:	SUITE 240
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1720
Country	:	US
Telephone Number	:	801-263-7225
Fax Number	:	201-263-7279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	07/08/2007

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